- Document Name
- Comfort Care/Do Not Resuscitate Order Verification
Custom Care/Do Not Resuscitate Order Verification With Bracelet
- Where do you get the form
- A physician must complete a DNR form on your behalf. If you want to order a bracelet, the physician will complete the DNR Order Verification With Bracelet form.
If your physician does not have a form, click here:
- Who signs the form
- The form is signed by the physician, the patient, and two witnesses. The DNR Verification with Bracelet form must be printed on 8 1/2 inch by 14 inch legal size paper.
- Patient Identification
- The Comfort Care/DNR verification is the only document that EMS personnel can use to verify a DNR order is valid.
- How do you obtain a DNR bracelet
- Your physician must order a DNR bracelet for you.
- Revoking a DNR
- An EMS/DNR Order may be revoked at any time by the patient’s request for resuscitation made directly to responding emergency medical services personnel OR by the physical cancellation or destruction of all EMS/DNR Order forms, bracelets, and necklaces with the consent of the patient or the authorized decision maker signing the EMS/DNR Order. Destruction of an EMS/DNR Order, bracelet, or necklaces without consent carries penalties under the Health Care Decision Act.
- Photocopies of the form or the bracelet inserts are not considered authentic DNR documents. If you need a document at more than one location, create multiple original documents.
- State info link
- Other links
- DNR Bracelet links
- Your physician must order a DNR braclet on your behalf.
- Special Notes
- Order a Vial of Life decal for your front door. The decal informs Emergency Medical Services team a DNR has been prepared and can be found in your refrigerator. The Customer Care/Do Not Resuscitate Order Verification assumes the patient has completed a separate DNR form. The DNR Order Verification form provides a way to document the existence of a DNR in out of hospital situations.